Report No. 752b-DO FILE Copy Appraisal of a Population and Family Health Project Dominican Republic August 31, 1976 Population Projects Department FOR OFFICIAL USE ONLY Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS US$1.00 r RD$1.00 A. ABBREVIATIONS ADPBF - Asociaci6n Dominicana Pro-Bienestar de la Familia (Dominican Association for Family Welfare) CAAE = Centros de Adiestramiento de Auxiliares de Enferme4fa (Nursing Auxiliary Training Centers) CBD = Community-Based Distribution of Contraceptives CEA = Consejo Estatal del Az6car (State Sugar Council) CODIA = Colegio de Ingenieros y Arquitectos (College of Engineers and Architects) CONAPOFA = Consejo Nacional de Poblaci6n y Familia (National Council for Family Planning) ENE Escuela Nacional de Enfermerfa (National Nursing School) GODR = Government of the Dominican Republic ICB = Internatiunal Competitive Bidding IDSS = Instituto Dominicano de Seguros Sociales (Dominican Social Security Institute) IEC = Information, Education and Communication IMR = Infant Mortality Rate INES = Instituto Nacional de Educaci6n Sexual (National Institute for Sex Education) INTEC = Instituto Tecnologico de Santo Domingo (Technological Institute of Santo Dominto) IPPF = International Planned Parenthood Federation IUD = Intra-Uterine Device MCH/FP = Maternal and Child Health/Family Planning ODC = Oficina de Desarrollo de la Comunidad (Office of Community Development) FOR OFFICIAL USE ONLY A. ABBREVIATIONS (cont'd) ONAPLAN = Office for National Planning PAHO = Pan American Health Organization PIU = Project Implementation Unit SESPAS = Secretarfa de Estado de Salud P'ublica y Asistencia Social (Secretariat of State of Public Health and Social Assistance) SSID = Servicio Social de las Iglesias Dominicanas (Social Service of Dominican Churches) UASD = Universidad Autonoma de Santo Domingo (Autonomous University of Santo Domingo) UCMM = Universidad Cat6lica Madre y Maestra (Catholic University Mother and Teacher) UNDP = United Nations Development Programme UNFPA = United Nations Fund for Population Activities UNPHU Universidad Nacional Pedro Henriquez UreTia (National UniverSbiy Pedro Henriquez Urena) USAID = United States Agency for International Development WHO - World Health Organization B. DEFINITIONS Birth Rate = Annual births per 1,000 population Death Rate = Annual deaths per 1,000 population Age-Specific Set of 6 or 7 rates obtained by dividing the number of Fertility Rates = annual births to mothers in each age interval from 15 to 45 or 49 ycars by the corresponLding female population in the same interval. Total Fertility Sum of age-specific rates, each multiplied by 5 Rate (usual age interval in years). It is interpreted as births per woman or per 1,000 women of child-bearing age (15-49 years). It is a more effective measure than the general fertility rate, since it takes into account age distribution of mothers. Rate of Natural = Difference between the crude birth and death rates Increase This document has a restricted distribution and may be used by recipients only in the performance of their omcial duties. Its contents may not otherwise be disclosud without World Bank authorization. B. DEFINITIONS (cont Id) Dependency Ratio = Persons of "dependent" ages (those under 15 years of age and age 65 and over) per person of ??working ages" 05-64 years). Infant Mortality = Annmal deaths of infants aged less than one year Rate per thousand live births. Graduate Nurse = Nurses who have completed 3 or 4 years of nursing education after completion of secondary school. Technical Nurse = A new category of nursing personnel (who will graduate in liceos); course will consist of two years of nursing after four years of secondary studies. Nursing Auxiliary Health worker with 6-9 months of nursing training after completion of the eight years of education. Practical Nurse = Nurses without formal training except experience. Liceos = Secondary Schools. Rural Clinics = Health facilities located in a rural area covering an estimated population of 2,500-3,000 staffed by one or two nursing auxiliaries and/or practical nurse and visited by a physician once a week. Health Sub-Centers = Health facilities with both outpatient and in- patient services; they have 10 to 30 beds mainly for deliveries and pediatric cases. Health Centers = Health facilities located in provincial capitals, providing mainly outpatient services. Integrated Hospitals For curative services and the prevention of disease, for health promotion and rehabilitation. DOMINICAN REPUBLIC: BASIC DATA Area (in Km ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48,734 Density (per Km ) 1974 .... . . . . . .... . . . . . . . . . . 94 - Density per arable land (Km ) 1972 ... . . ..... . . . . . . . 232 Population (in millions) Mid 1974 (est.) . . . . . . . . . . . . . . 4.56 Birth Rate (per 1,000). . . . . . . . . . . . . . . . . . . . . . . . 47.5-/ Death Rate (per 1,000). . . . . . . . . . . . . . . . . . . . . . . . 14.5 - Infant Mortality Rate (per 1,000) . . . . . . . . . . . . . . . . . . 104.0 -/ Rate of Natural Increase. . . . . . . . . . . . . . . . . . . . . . . 3.3%-/ Life Expectancy (1959-61) ................... . Men 57.15a/ Women 58.59 - Total Fertility Rate. . . . . . . . . . . . . . . . . . . . . . . . . 7.1-/ Age Structure (%) b/ Under 15 years .... . . . . . . . . . . . . . . . . . . . . 48%- 15-64 years .... . . . . . . . . . . . . . . . . . . . . . . 49%-/ 65 and over . . . . . . . . . . . . . . . . . . . . . . . . . . 3%b/ Women 15-49 years (in millions) 1974 ... . . .... . . . . . . . 1.02 b Proportion Married (1970) ............. . 66% l d/ Family Planning New Acceptors (in thousands) 1974 . . . . . . . . . . 38.1 -/ Percentage of Rural Population (1970) .......... . 60%-/ Literacy Rate (10 years and over) .... . . . . . . . . . . . Male 697 Female 67% Adult Literacy rates (15 years and over) . . . . . . . . . . . . . . 51% - Unemployment Rate (Santo Domingo) 1973. 20I- Population Per Physician . . . . . . . . . . . . . . . . . . . . . . 2,100 -/ Population Per Hospital Bed ........ .......... .. . 350 -/ Population Per Nursing Person ....... ........... . . 3,930-/ Dependency Ratio (age) . . . . . . . . . . . . . . . . . . . . . . . 1.04 GNF (in US$ millions at 1973 market prices) ..2,310 GNP Per Capita 0JS$) 1973 ..520&/ a/ United Nations Demographic Yearbook 1974, Based on 1970 Census data. b/ 1970 Census Data. c/ Data for 1973. Health Sector Assessment for the Dominican Republic (Feb. 1975). d/ Half of these live in consensual marriage. e/ Population Council. Reports on Population/Family Planning 'Factbook', Oct. 1975. f/ International Labour Organization "Generaci6n de empleo, producci6n y crecimiento economico - El caso de la Rep'ublica Dominicana", Geneva, 1975. g/ World Bank Atlas, 1975. DOMINICAN REPUBLIC APPRAISAL OF A POPULATION AND FAMILY HEALTH PROJECT TABLE OF CONT7'i'4S Page No. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . 1 . . . A. Background . . . . . . . . . . . . . . . . . . . . . . . 1 B. The Population Problem . . . . . . . . . . . . . . . . . 1 II. HEALTH SERVICES . . . . . . . . . . . . . . . . . . . . . . . 3 A. Background . . . . . . . . . . . . . . . . ... . . . . . 3 B. The Secretariat of Health . . . . . . . . . . . . . . . . 4 C. Health Manpower . . . . . 6 . . . . . . . . . . . . . . . 6 III. THE NATIONAL FAMILY PLANNING PROGRAM . . . . . . . . . . . . 9 A. Participating Agencies . . . . . . . . . . . . . . . . . 9 B. Program Financing . . . . . . . . . . . . . . . . . . . . 11 C. Family Planning Program Performance . . . . . . . . . . . 12 IV. THE PROJECT . . . . . . . . . . . . . . . . . . . . . . . . . 14 A. Objectives and Strategy . . . . . . . . . . . . . . . . . 14 B. Project Components . . . . . . . . . . . . . . . . . . . 15 C. Detailed Project Features . . . . . . . . . . . . . . . . 17 V. PROJECT COST, FINANCING, DISBURSEMENT AND IMPLEMENTATION . . . . . . . . . . . . . . . . . . . . . 26 A. Cost . . . . . . . . . . . . . . . . . . . . . . . . . . 26 B. Proposed Financing . . . . . . . . . . . . . . . . . . . 28 C. Procurement . . . . . . . . . . . . . . . . . . . . . . . 28 D. Implementation . . . . . . . . . . . . . . . . . . . . . 29 E. Disbursements . . . . . . . . . . . . . . . . . . . . . . 30 F. Accounts and Audit . . . . . . . . . . . . . . . . . . 31 This report is based on the findings of an Appraisal Mission which visited the Dominican Republic from November 4-23, 1974, and an up-dating Mission conducted from February 17 to 27, 1976 at the Government's request to re-initiate discussions on this project, after an interruption of almost one year, while terms of project financing were being reconsidered. The first mission consisted of Mrs. M. N. Maraviglia (Population Specialist), Mrs. T. V. Tiglao (Education and Training Specialist), and Mr. H. W. Franckson (Architect), all from the Bank; Mrs. A. Debuchy, Architect/Health Planner (Consultant), Mr. M. Le Mandat, Architect (Con- sultant), and Miss N. Gordillo, WHO/PAHO Nurse Educator (Consultant). The second mission consisted of Mrs. M. N. Maraviglia and Mrs. T. V. Tiglao, with the parti- cipation of Miss N. Gordillo (WHO/PAHO-DR). Table of Contents (Continued) Page No. VI. PROJECT JUSTIFICATION . . . . . . . . . . . . . . . . . . . 31 VII. AGREEMENTS REACHED AND RECOMMENDATION . . . . . . . . . . 32 ANNEXES 1. Demographic Analysis 2. 1973 Expenditures in Health Care by Institution and Estimated Target Population 3. Secretariat of State of Public Health and Social Assistance (SESPAS) Organizational Chart 4. Existing Health Facilities in the Dominican Republic (SESPAS and IDSS) by Region and by Type 5. Training of Nursing Personnel 6. The National Council for Family Planning (CONAPOFA) 7. Comprehensive Health Care 8. Technical Assistance and Training Courses in the Project 9. Program of Community-Based Distribution of Contraceptives 10. Project Implementation 11. Civil Works 12. Costs of Non-Construction Project Components 13. Financing Plan - By Type of Expenditure - By Functional Category 14. Estimated Disbursements 15. Estimated Project Effects in Regions I and V, 1975-1981 MAP IBRD 11188 Dominican Republic - Location of Proposed and Existing Health Facilities DOMINICAN REPUBLIC Appraisal of a Population and Family Health Project Summary and Conclusions i. This report appraises a population and family health project in the Dominican Republic for which a Bank loan of US$5.0 million equivalent on Third Window terms is proposed. This three-year project has been designed to assist the Government in the development of a comprehensive health/family planning program. Through this program, the health and welfare of the population, particuiarly of mothers and children living in rural and semi-rural areas, would be enhanced. The long-term result of this program would be a significant reduction in the rate of population growth. During preparation and appraisal of this project, due attention has been given to the present and prospective assistance from other donor agencies, particularly the United States Agency for International Development (USAID) and the United Nations Fund for Population Activities (UNFPA). Coordination among donors has been effected through close and frequent consultation. ii. The Dominican Republic is experiencing an exceptionally high rate of natural population increase. A considerable net emigration has kept the annual growth of population just under 3% in recent years. However, if the high birth rate (47.5 per 1,000 in 1965-70) and the death rate (14.5 per 1,000) continue at current levels, the present population of more than four million would double in about 22 years. The young population structure (48% under the age of 15) means a high dependency ratio (1.04), large investments in health services and educa- tion, and a built-in momentum for continued rapid population growth. A rela- tively unchanged literacy rate (2% increase between 1960-1970) indicates the educational systemi is already experiencing difficulty in keeping pace with the population growth. Unemployment and underemployment are high (about 40%). The need for fertility decline is especially urgent because of the rapidly increas- ing rates of unemployment and increasing aspirations for better educational opportunities and more complete health services The prospect of further mor- tality reduction makes the need for fertility decline more urgent. iii. The project proposes that family planning services be offered within the context of a comprehensive community health care program; delivery of these services would be primarily through the health delivery system of the Secretariat of State of Public Health and Social Assistance (SESPAS). SESPAS is the Government agency responsible for providing health services to approximately 68% of the population. However, it was recently estimated that SESPAS delivered health services to only 37% of the population; other Government agencies serve about 15% and the private sector takes care of 17%, This leaves about one-third of the population with no health services.L/ The Government recognizes that to ex- pand the health delivery system, the present emphasis on expensive, curative 1/ USAID Health Sector Assessment for the Dominican Republic, February 1975. - ii - services must be shifted to an emphasis on preventive, community-based health services. To effect this change, SESPAS must first undergo a re- organization and strengthen its management; a USAID health loan signed in October 1975, includes technical assistance for this. SESPAS' existing facilities will be expanded from the urban centers to the rural areas. New channels will be developed outside of SESPAS for delivering health services at the village level by drawing on other health-related agencies. Paramedi- cal health workers will be trained to staff the new clinics; they will also go into the villages, both to educate the people on preventive health measures and totreat the sick. iv. Voluntary organizations were responsible for introducing the concept of family planning in the early sixties. The Dominican Association for Family Welfare (ADPBF), founded in 1966 and affiliated with the International Planned Parenthood Federation (IPPF), has been the country's main non-Governmental or- ganization concerned with family planning. Another private organization, the Social Service of Dominican Churches (SSID), began promotion of family plan- ning in 1962 and formal programs of community-based distribution of contracep- tives in 1972. Official action came in 1968, with the establishment of the National Council for Family Planning (CONAPOFA) by Presidential Decree. The delivery of family planning services, while the principal responsibility of CONAPOFA, is shared by other Governmental and non-Governmental agencies, the most important of which is SESPAS. V. The existing family plann:ng program has not had a significant effect on fertility to date (only 6.5% of fertile women currently practice contraception). Chief among the constraints limiting the possible impact of the family planning program are: (a) the population is predominantly rural and poorly educated; (b) the near-universality of marriage (2/3 of all eligible women are either married or live in consensual unions) and early age at marriage; (c) high in- fant mortality; (d) family planning facilities that are usually inaccessible, inconvenient, inadequately staffed and inadequately equipped; and (e)health personnel who are inadequately trained (or overtrained) and distributed un- evenly throughout the population. Those who suffer the most from these limita- tions are the rural poor. With technical assistance from the Population Council and financing from UNFPA, CONAPOFA is currently attempting to reduce these con- straints by using paramedical staff to deliver family planning services. How- ever, intensified training efforts are required to extend these services to a greater portion of the population. Additional family planning services are being created by SESPAS with assistance from CONAPOFA; these efforts, too, need more support. vi. The proposed project includes the construction and equipping of 26 rural health clinics in Regions I and V and one health sub-center in Region V, in locations strategically selected to provide services to the rural and semi- rural population which now has only minimal access to health and family plan- ning services. It would finance a variety of training activities, fellowships for local production of nursing personnel and travel allowances to improve - iii - service supervision of clinics in rural areas of Regions I and V. These components would enable the establishment of a comprehensive health delivery system in those Regions, with due emphasis on preventive care and family planning activities. In addition, several national universities would field medical and nursing students in these Regions to render basic health services along with the regular SESPAS staff. The proposed project would, furthermore, finance equipment, vehicles and fellowships, so that nursing schools and technical and auxiliary courses may increase their output to alleviate present nursing personnel shortages. Technical assistance financed by the project would include (a) a total of 68 man-months of senior advisory services and 24 man-months of associate (mainly graduate level) advisory services (at an average annual cost of US$35,000 and US$20,000 respectively, excluding in- ternational and local travel expenses) for health service delivery, health administration, information systems and statistics, research, curricula modi- fication, maintenance training program, facilities eval' iion, and procurement, and (b) four 12-month fellowships and six months-of study tours. Operating costs for several training programs and seminars would also be part of project financing. In order to assist CONAPOFA in immediately establishing a strong program of family planning, training and motivation in the whole country, the proposed project would finance allowances for six family planning training coordinators and support staff (one team for each of the six Health Regions), operating costs for training about 400 community workers in family planning, and operating costs of conferences and seminars to educate about 130,000 persons in family planning over the three-year period. Seminars for about 300 teachers of teacheis, to be conducted by CONAPOFA, would also be included in this project. In addition, the project would finance operating costs for a program of community-based distribution of contraceptives in rural areas of the country not yet covered with health and family planning services, to be implemented by the Social Service of Dominican Churches under the supervision of CONAPOFA and in coordination with the Government's family planning services. vii. The Government has established a Project Implementation Unit (PIU) in SESPAS to oversee project administration, accounting, construction, procure- ment and training, and it has appointed, under terms and conditions that were acceptable to the Bank, the Project Director, Deputy Director, Architect and Training Coordinator. During negotiations, the Government agreed that, in order to review project progress and plan its execution, the project staff, the Directors of Health Regions I and V and senior officials from CONAPOFA, the Technical Secretariat of t;.e Presidency and the universities and other agencies par- ticipating in the project, will meet at least every four months during the execution of the project, under the Chairmanship of the Secretary of Health and Social Assistance. The Government also agreed to make the appointments of all consultants to be used in the project under terms and conditions accept- able to the Bank. The establishment of a project account and the initial deposit of an amount equivalent to not less than US$300,000 is a condition of loan effectiveness. viii. Total project costs are estimated at US$7.5 million equivalent. The proposed loan of US$5.0 million equivalent (67%) would cover US$2.4 million of foreign exchange and US$2.6 million equivalent of local costs on project grounds; - iv - the Government would contribute US$2.5 million equivalent (33%). The Bank loan would include retroactive financing not to exceed US$83,000 to cover expenses incurred by the Government since March 1, 1976 to start project preparation and train staff. ix. All contracts over US$200,000 for civil works, and all contracts over US$80,000 for furniture, equipment, special equipment and vehicles will be awarded on the basis of International Competitive Bidding. Contracts for civil works not exceeding US$200,000 and in aggregate not exceeding US$400,000, and contracts for vehicles, furniture, equipment and special equipment not ex- ceeding US$80,000 and in aggregate not exceeding US$200,000, will be awarded on the basis of competitive bidding advertised locally. In all cases, con- tractors for civil works will be prequalified. Domestic manufacturers of furniture and equipment will be accorded a margin of preference equal to 15% of the c.i.f. cost of competing imports or the applicable customs duties, whichever is lower. x. It is expected that the project, through the improvements it would make to health/family planning service delivery and creation of demand for family planning, would contribute directly to over one-fourth of the fertility decline to be achieved by the family planning program during the next 25 years. In the short run, by 1981, services in the project areas would be provided to 48,000 contraceptive users, and the delivery system would be about three times as effective as at present. The project would assist, too, in improving over- all family planning program performance through assistance to CONAPOFA's training program and promotion of family planning through the community workers. The project would also make major contributions to improvement and expansion of the health delivery system, through training and improved supervision; a wider set of health benefits, particularly to rural mothers and children, would result. xi. The proposed project constitutes a suitable basis for a Bank loan of US$5.0 million equivalent to the Government of the Dominican Republic on standard Third Window terms. I. INTRODUCTION A. Background 1.01 This report appraises a population and family health project de- signed to help the Government of the Dominican Republic (GODR) achieve its goal of slowing down the country's high rate of population growth. The country has had an official population policy since 1968, when the Government established a special inter-agency authority to deal with the problem and be- gan offering family planning services through Governmental health facilities. Government efforts have been supplemented by a number of private activities and are being supported financially by external assistance from the United States Agency for International Development (USAID), the United Nations Fund for Population Activities (UNFPA), and, in the private sector, by the Inter- national Planned Parenthood Federation (IPPF), the Church World Service, and other donors. Despite these efforts, program performance has not yet achieved much momentum and today only about 6.5% of the eligible couples are active users of modern services, notwithstanding considerable evidence of un- satisfied demand. Improved performance will depend primarily on better or- ganization and administration of health and family planning services, a shift in the concept of health care, with greater emphasis on rural and preventive activi4ties a restructuring of health occupations (especially within the nursing profession), and a considerable expansion of health manpower. The Government recognizes these problems and has started to deal with them. The project will assist the Government in introducing the needed changes; although some project activities will be nation-wide in scope, the major effort, intended as a first stage, is concentrated on two of six Health Regions (Regions I and V). B. The Population Problem 1.02 The population of the Dominican Republic in the 1970 census was four million, having doubled in the last 20 years. On the basis of census data, the birth rate in 1965-1970 was estimated at 47.5 per 1,000, and the death rate at 14.5 per 1,000. producing a rate of natlural increase of 3.3Z, among the highest in the world.L' The average number of children born to women by the end of their reproductive years was 6.8 on the basis of the 1970 census. The infant mortality rate (IMR) is still high, around 104 per 1,000 live births, one of the highest in Latin America and about four times that found in developed coun- tries. In rural areas the IMR was almost 130 per 1,000 live births.2/ Such a high infant mortality rate presents an obstacle to creating a desire for birth limitation. 1/ Data from a survey undertaken in 1974 as part of the USAID-sponsored Health Sector Assessment show that the birth rate in 1973 was 45 per 1,000 and the death rate was 15 per 1,000. 2/ USAID Health Sector Assessment for the Dominican Republic, February 1975. .- 2 - 1.03 The popilation is young w-th 48% under the age of 15, resulting in a dependency ratio of 1.04--twice that typical of developed countries. This age str"'cture implies a need for heavy expenditures on health services and education; it also provides a built-in momentum for continuing rapid popula- tion growth. According to the 1970 census, the literacy rate was 68% for 10 years or older, an increase of only two points since 1960. The slow improve- ment of the literacy level in the last decade is due principally to the inability of the educational system to expand rapidly enough to offset popu- lation increases. 1.04 Despite rapid economic expansion, unemployment and underemployment are persistent throughout the econoEy. From 1960 to 1970, the labor force increased 3% annually with urban labor increasing by 5.5% per year. The ILO has estimated unemployment and underemployment at 40% in the whole country, 1/ a problem more serious than in most other Latin American countries. Since the labor force is expanding faster than employment opportunities, high unemploy- ment and underemployment can be expected to continue in spite of the Govern- ment's efforts to reduce it. 1.05 Two illustrative population projections show the alternative trends in the next quarter century under the following assumptions of fertility decline: Projection A: almnst constant high fertility during the period; Projection B: moderately rapid decline in the total fertility rate to about 73% of the 1970 value by 1980, and to 47% by 2000. 1.06 In both projections, life expectancy is assumed to increase from 52 to 60 years for males and from 55 to 63 years for females by the year 2000. Projection A estimates the population trend in the absence of a family planning program and serves as a basis to measure the fertility reduction needed to achieve Projection B (Annex 1 contains detailed tables). The alternative projections are as follows: Population Projections Per 1000 Population Natural Birth Rate Death Rate Increase Year (A) Constant (B) Declining A B A B A B 1970 4,000,000 4,000,000 47.5 47.5 14.5 14.5 3.3 3.3 1980 5,700,000 5,300,000 50.2 39.1 11.8 10.9 3.8 2.8 1990 8,400,000 7,000,000 47.2 33.7 9.6 9.1 3.8 2.5 2000 12,300,000 8,800,000 46.9 27.0 8.2 7.9 3.9 1.9 1/ International Labor Organization, "Ceneracion de empleo, produccion y crecimiento economico - El caso de la Rep'ublica Dominicana," Geneva, 1975 -3- 1.07 These estimates serve to underline the serious implications of delays in reducing fertility. The assumption of constant fertility up to the year 2000 gives an upper limit of 12.3 million persons in that year -- three times that of the 1970 population figure. The lower population total (8.8 million) would be realized if couples practised family limitation to the extent of having almost four million fewer births during the next 24 years. 1.08 The need for fertility decline in the Dominican Republic is, there- fore, especially urgent because of high unemployment, rising aspirations for improved standards of living, and prospects of further improvements in life expectancy. II. HEALTH SERVICES A. Background 2.01 An understanding of the health services in the Dominican Republic is essential to assess their potential and the changes which would be required in order that they may serve as an effective basis for the family planning services. The Secretariat of State of Public Health and Social Assistance (SESPAS) is the main Governmental health agency; it is responsible for providing health services to low-income families, persons not on social security, and gersons who are not in the Armed Forces -- approximately 68% of the population.l However, it was recently estimated that SESPAS delivered services to only 37% of the total population (1.7 million in 1973). The Dominican Social Security Institute (IDSS) provides medical services to persons on social security, the State Sugar Council (CEA) to sugar workers and the Armed Forces to its personnel and their families (in total, about 15% of the population). The private sector is assumed to take care of about 17% of the country's population. The one-third of the population not served is principally composed of low income, rural families. SESPAS has limited trained staff and its facilities are concentrated in urban areas. Furthermore, the nature of services rendered by the agencies differs greatly; this is indicated by the average expenditure per person, which, in 1973, varied from about RD$1 for CEA, and RD$7 for SESPAS, to RD$67 for the IDSS, and RD$70 for the private sector (Annex 2). Of total health expenditures on personal health services in 1973 (RD$107 million), about 50% were in the private sector, and only 20% were channelled through SESPAS. 2.02 Health services currently provided by SESPAS are oriented around hos- pitals. This is an expensive means of delivering health care; over 80% of SESPAS' expenditures in 1972-73 were for curative health care services. The Government plans to emphasize the use of paramedical health workers operating in simple rural clinics and paraprofessionals working in the communities. 1/ Source of information on coverage and cost of health services: USAID Health Sector Assessment for the Dominican Republic, February 1975. The rural clinics would be linked (via radio communication and vehicles) to strategically located health centers and hospitals for referral of difficult medical problems. SESPAS also plans a shift in emphasis towards preventive health care (vaccinations, maternal and child health care and health and nutrition education) and diagnosis of health problems at the level of the community. B. The Secretariat of Health 2.03 SESPAS is administered by a Secretary of Public Health and Social Assistance, appointed by the President of the Republic. The Secretariat is divided into two sub-secretariats -- one for Health and one for Social Assis- tance (the organizational chart is given in Annex 3). The Secretary is ad- vised by a Technical Council. The Pan American Health Organization (PAHO) also provides advice. SESPAS provides healt1 services through 244 facilities of various types which include 84 hospitalsl with 6,945 beds, and around 160 outpatient facilities (Annex 4 presents a distribution of health facili- ties by Region). In 1975, the staff was formed by 830 doctors, 250 registered nurses, and about 1,300 nursing auxiliaries (elementary school plus six months' training). There were also dver 1,000 "practical" (untrained) nurses working in SESPAS' services; they are being upgraded through training to nursing auxiliaires through a p-rogram that is expected to be completed by mid-1977.2/ Both physical facilities and staff are unevenly distributed throughout the country, concentrated in Santo Domingo and a few large urban centers. Most rural centers are operated by auxiliary personnel, who are supposed to be supervised weekly by doctors or nurses; however, in most places supervision of services is higkhly inadequate. 2.04 During the 1960's SESPAS, with help from PAHO, initiated a region- alization plan for its health services. The country was divided into five Health Regions and each Region was fur ther divided into areas. In late 1975, Region IV in the Southwest was subdivided, thus creating a new Region I. The health area, which is the basic operational unit for services, has one inte- grated health center or base hospital -- which constitutes the headquarters of the Area Director -- in addition to three or four sub-centers and five or six rural clinics (an organizational chart for Regional offices is included in Annex 10). The following table shows the structure and staffing pattern of the comprehensive health care system being partially implemented in Health Region II and which will be made possible through this project in Health Regions I and V. 1/ Hospitals and other establishments with beds. 2/ As of April 1976, SESPAS had up-graded 1,060 "practical" nurses to auxiliar- ies and it was planning to complete this training program in three more semesters, through 18 courses of 15 students each. -5- Health Care Level Service Provided Type of Facility Personnel Needed Primary Health promotion Rural clinics Per Rural Clinic: Specific protection (1 per 12,000 pop. 1 Nursing Auxiliary Preventive care - 1OKm radius) 1 Clerk (assistant) Community Organiza- 2 Medical/Nursing students tions 1 Paraprofessional (pro- motor/community worker) per 450 pop. Secondary Supervision to pri- Health Center Per Health Sub-Centerl/ mary level Health Sub-center (30 beds/outpatient) Early diagnosis General Hospital 2-3 doctors Specific treatment ("Area" headquar- 1 Graduate nurse ters - 1 facility 16 Nursing Auxiliaries per 4-5 rural 7 other health profes- clinics) sionals Maintenance staff Tertiary Curative Services Specialized Hospi- Specialized Doctors Disability limita- tals General Practitioners tion General Hospitals Graduate Nurses Nursing Auxiliaties / A General Hospital with a varying staffing pattern according to number of beds, may also serve as "area" headquarters. A Health Center is an outpatient facility located in a provincial capital with services in several medical specialities. 2.05 Regionalization has proceeded slowly, mainly due to lack of administra- tive capability, inadequate delegation of responsibility from the central level to the Regions and the areas, and lack of Regional autonomy in day-to-day finan- cial matters. In order to be fully effective it is essential that the Regional Directors be given authority and responsibility for day-to-day management of the health services and for implementation of the project in their respective Regions, and be provided with an adequate budget for efficient day-to-day operations. During negotiations, assurances were obtained from the Government that it intends to confer upon the Directors of Regions I and V the above authority and responsi- bilities. In addition, the Government agreed to cause the health personnel working in such Regions to be paid wages only upon performance of their respective assignments and to consult with the Directors of Health Regions I and V before making any personnel appointments,transfers and dismissals and creating new positions in their respective Regions. - 6 - 2.06 Planning, programming, organization and management of staff and physical resources are areas in which SESPAS requires strengthening. The Government recognizes this need, and is taking steps to improve its manage- ment. A Director for Administrative Reform has been recently appointed, with some supporting staff. PAHO/WHO has provided technical assistance to define terms of reference for management consultants and the selection of a firm of management consultants is to be completed within a month's time, as part of the USAID-financed health project. These actions would be requisites for the successful extension of the experiences of the proposed project in Regions I and V to other parts of the country. C. Health Manpower Existing Situation 2.07 There are five critical problems of health manpower which directly affect the provision of family planning services: (a) There are serious imbalances within the occupational structure of the nursing profession -- far too few nursing auxiliaries and regis- tered nurses; (b) There is a severe shortage of nursing tutors, so that the capacity for training nurses cannot be expanded significantly until more tutors are properly trained; (c) Physicians and registered nurses are maldistributed geographically; they are heavily concentrated in urban hospital service, leaving many rural posts unfilled; (d) Government pay scales for health personnel are very low, making it difficult to expect full-time work, as many employees must hold outside employment; and (e) There is an over-production of doctors in relation to the absorptive capacity of the present health care system; consequently, a heavy "brain drain" wastes the educational investment. 2.08 The Government recognizes these problems and is prepared to work to- ward satisfactory solutions within the context of existing resource limitations. With the assistance of studies and advice from PAHO, USAID and more recently the Bank, the Government has developed plans to: (a) step up the output of nursing personnel of all categories, (b) establish a new intermediate category -- the technical nurse, (c) distribute nursing training facilities more evenly throughout the country in order to encourage personnel to stay in rural areas, and (d) assign medical and nursing students to provide six months of service in - 7 - rural areas as part of their training. (A description of project components designed to assist implementation of these plans begins with para 4.12.) In addition, as part of this project's preparation, the SESPAS entered into ar- rangements with the Autonomous University of Santo Domingo (UASD) to conduct a semester course (completed in November, 1975) on pedagogical methods. Twenty tutors, needed for project activities, completed the course. 2.09 Salaries for SESPAS nursing staff were increased during 1975. During negotiations, assurances were obtained from the Government that it will review the salary levels for nursing personnel from time to time and it will revise them if necessary in order to insure: (a) that salaries will provide sufficient incentives for people to enter and remain in the nursing profession, and (b) that salaries are structured to provide sufficient incentive for services in rural areas. Physicians 2.10 Four new medical schools have been created since 1965; consequently, the country now has the second highest ratio of medical students to population in Latin America (12 per 10,000). This investment is not efficient because the country cannot absorb all graduates into the health system. Many physicians will continue to emigrate or shift to other occupations. The Government could take advantage of this situation by using the services of medical (and nursing) students under a carefully planned and super-vised program. Through the pro- posed project at least three Dominican Universities with schools of medicine would have their medical students doing field practice in Regions I and V. The Technological Institute of Santo Domingo (INTEC) and the Universidad Nacional Pedro Henriquez Ureta (UNPHU) have both agreed to participate. These universities would, on the basis of those experiences, review and if necessary modify the curricula of their medical schools to introduce the concept of com- munity-based health care with emphasis on preventive and family planning ser- vices.0 During negotiations agreement was reached with the Govzernment that within six months from the date of loan effectiveness it will sign agreements with at least three universities to the effects described above. Nursing Personnel 2.11 There are not enough nurses to staff health facilities adequately. The Government plans, with the assistance of the proposed project, to increase the number of graduate nurses, to introduce a new category of "technical nurses" (four years of basic secondary studies plus two years of nursing training), to phase out the practical (untrained) nurses referred to in para. 2.03 and to in- crease the number of nursing auxiliaries. The existing number of nurses in each category and the planned increase up to 1980 are given in the following table (details on categories of nursing personnel and on training facilities are given in Annex 5). 1/ The INTEC already has a curriculum especially oriented toward community-based health services and it would use the field experience to make further cur- ricular improvements as necessary. -8- Present Planned Increase Target Nursing Categories NuTrber (1976-1980) for 1980!- Graduate (professional) Nurses :368 324 692 Technical Nurses - 316 55921 Nursing Auxiliaries 2,068 1,240 3,308 Total 2436 1880 4 559 1J As stated in the Health Plan for 1976-80. 2/ Due to the delay of over one year in initiating courses, the planned in- crease is now 243 less than the original target. 2.12 The number of graduate nurses in the country (368) is the lowest per capita in Latin America (less than one per 10,000 population compared to the average of about 2.3 for Latin America). Only 25-30 nurses graduate annually from the two nursing schools (the National Nursing School (EN-E) operted by SESPAS and the Universidad Cat6lica Madre y Maestra (UCMM). The UASD started a nursing school in June 1976. The Bank project would contribute 50%6of the- annual increases needed to reach the Government's goal of about 700 graduate nurs6s in 1980, by financing local fellowships in existing schools. 2.13 The program to train the intermediate grade of "technical nurses" is under the Secretariat of Education as part of the Education Reform Program. This course of study will be offered initially in one, and by 1978, in three secondary schools. The project would support this program by providing teaching equipment, materials and vehicles (equipment and materials for the nurses' training program were provided under the first Bank-assisted Education Project). 2.14 Nursing auxiliaries are a key to the delivery of low-cost health ser- vices and an expansion of the fami]y planning program. For auxiliaries ren- dering basic health care in rural clinics (first aid, pre-natal and pediatric check-ups, vaccinations, family planning), a two-way radio communication system would be provided through this project; auxiliaries could then consult the health center or hospital and call ambulances in emergency situations. 2.15 There is a need to accelerate the training of new auxiliaries and there are plans to increase their number from about 2,000 to 3,300 in the next five years. This increase will require stepping up the training of graduate nurses and technical nurses, who will be needed for supervision in increasing numbers. It is estimated that about 230 to 270 auxiliaries will be graduating yearly be- tween 1976 and 1980. -9- III. THE NATIONAL FAMILY PLAN;NING PROGRAM A. Participating Agencies Background 3.01 The first family planning activities in the Dominican Republic were sponsored by the Social Action Council of the Dominican Evangelist Church in 1962. In 1966 the Dominican Association for Family Welfare (ADPBF) was for- mally established by the same group: it soon extended family planning services to 26 localities, using private doctors. In 1968, the Association began re- ceiving assistance from the International Planned Parenthood Federation (IPPF). In that same year the Government established, by Presidential Decree, a national family planning program intended to reduce maternal and infant mortality, abor- tions and population growth. A new agency, the National Council for Family Planning (CONAPOFA), was created and, initially, made responsible for studies, research, analysis and publication of population-related matters. A later regulation (December 1969) gave CONAPOFA the added responsibility of advising the SESPAS in establishing a family planning service program. Since that time, CONAPOFA has been engaged mainly in the direct provision of those services, using the health facilities and staff (sometimes paying them for additional hours of work) of five Government agencies and one private organization. 3.02 Five differentGovernment agencies and one privately-sponsored agency offer family planning services through clinics.l/ Currently (August 1976) CONAPOFA operates, in SESPAS' facilities, about 86% of the clinics providing family planning services. The other Government agencies offering services are IDSS, CEA, the National Police and the Armed Forces; the private agency is ADPBF. There are 237 family planning clinics in operation;- CONAPOFA plans to in- crease the number of these clinics to 258 by the end of 1976. The contraceptive methods offered in these clinics are the Intra-Uterine Device (IUD), oral con- traceptives, condoms, foams and vaginal tablets. Clinics do not offer male or female sterilization as methods of fertility control. There are also two Govern- ment agencies (the Secretariat of Agriculture and the Office of Community Development--ODC) and three voluntary organizations that are active in family planning education and motivation work, and two national universities which pro- vide technical and research assistance to the program. CONAPOFA 3.03 Since its creation in 1968, CONAPOFA has been the official agency re- sponsible for planning the population program, coordinating the activities of all public and private agencies active in the field, and organizing family 1/ A "family planning clinic" is a health facility (hospital, health center or rural clinic) which offers family planning services on a part-time or session basis, in addition to other services such as care of the sick, first aid, im- munizations, pre-natal and routine child health care and nutrition education. 2/ Of the 237 clinics in operation, 23 are in Region I, 68 in Region II, 40 in Region III, 42 in Region IV, 25 in Region V, and 39 in the Nucleo Central (See Annex 6, p. 5). Four of the 237 clinics are operated by doctors in private practice. L - planning services within the official health delivery system. It is an inter- agency body,II and has a full-time staff of 35 professionals organized into four divisions: ad7inistration; medical; research and evaluation; and informa- tion, education, communication (IEC) and training. (Details on CONAPOFA's Divisions are presented in Annex 6). 3.04 The Executive Secretary is appointed by the President and assumes the total responsibility for decision-making. He has the authority to select and discharge his staff, subject to the approval of the President. Insuffi- cient delegation of responsibility has, in the past, hampered effective func- tioning of the organization as well as limited opportunities for the CONAPOFA staff to exercise initiative and responsibility in its work. The need to im- prove internal coordination and to promote staff morale has been recognized by the Executive Secretary. Management consultants were recently engaged to develop a reliable system that would minimize these organizational constraints. The appointment of a full-time administrative officer in late 1974 was another positive step. 3.05 CONAPOFA's Medical Division at the central level is responsible for providing technical supervision for the clinical family planning work of all medical and paramedical personnel. The regional supervisory team consists of one doctor, one nurse and one social assistant who report to the National Medi- cal Division Supervisors. Better cooperation between the CONAPOFA supervisory teams and the health personnel of SESPAS is needed. 3.06 CONAPOFA's Evaluation Division focuses on assessing the impact of the family planning program. A new statistical system, developed with UNFPA finan- cing, has enabled CONAPOFA to identify priorities in establishing new clinics. The Research Division is responsible for undertaking studies to help establish program priorities, research on the effectiveness of various communication stra- tegies and research on attitudes towqard birth control methods. There is a need for considerable expansion of this D)ivision's activities. This project will enable the development of a research plan and the implementation of research activities, including the analysis of data from the National Fertility Survey. 3.07 Since ADPBF is the agency primarily involved in information, educa- tion and communication (IEC) services for the national family planning program, the new IEC/Training Division of COIZAPOFA is assuming a complementary role, and will coordinate the activities of ADPBF with other agencies as the IEC services expand. Administration of the training and motivation programs in family plan- ning is also the function of this Division. Since its establishment, CONAPOFA, 1/ The members are the Secretary oi Health (Chairman); the Secretaries of Labor, Agriculture and Education; the Executive Director of the ADPBF; the Director of the Maternal and Child Health Division of SESPAS; and the Executive Secre- tary of CONAPOFA. - 11 - initially with the assistance of ADPBF, has trained 907 health personnel in family planning; this is approximately 16% of the existing health personnel. Due to limited financial and human resources, training in family planning pro- ceeded at a slow pace during the first seven years of the program. Conse- quently, the backlog to be trained was about 6,000 in 1976. The Bank project would support CONAPOFA's training and motivational activities. Agencies Working in Motivation-Education 3.08 The ODC and the Secretariat of Agriculture participate in community development programs through their social promoters and extension workers. With the assistance of CONAPOFA for training, and under its coordination, they are starting to engage in some motivational work for family planning. 3.09 Three private organizations are making important contributions to the program. Their family planning activities, however, are limited by mana- gerial and financial constraints. The ADPBF operates a nation-wide radio pro- gram on responsible parenthood and family planning, and handles production of material for IEC purposes. The National Institute for Sex Education (INES) is mainly responsible for sex education, including family planning, for teachers, community leaders, parents and students. 3.10 In 1971, the Social Service of Dominican Churches (SSID) (an organi- zation affiliated with the Church World Service, which includes the Evangelist Church) adopted a policy in support of family planning activities In 1972, it started a program of motivation/education and community-based dis- tribution of contraceptives in three provinces. The Bank project would finance operating costs for a community-based distribution of contraceptives program to be implemented by the SSID under the supervision of CONAPOFA. B. Program Financing Family Planning Program 3.11 Before the establishment of CONAPOFA, the then-existing private family planning activities were funded almost entirely by external private grant assistance, some of which continues (e.g., ADPBF received over US$180,000 in 1972 -- and the SSID, over US$37,000 in 1974 -- from the Family Planning International Association). USAID provided US$572,000 to the Government in 1968 and US$97,000 in 1970. In addition, in 1969, USAID. signed a US$7.1 million health loan to assist the expansion of maternal and child health services (para. 3.13). 3.12 In June 1973, UNFPA signed an agreement with the Government for a grant of US$1.9 million for a four-year Program of support to the national family planning program. Under this agreement the Government is contributing counterpart funds of an equal amount. The Population Council, New York, is providing advisers to CONAPOFA in evaluation and medical services for this pro- ject. - 12 - USAID Health Assistance 3.13 The 1969 US$7.1 million USAID health loan helped finance construc- tion of health facilities for SESPAS (47% of total loan), equipment (31%), training (15%), technical assistance (3%), special studies (2%) and mass media programs (2%). The principal problems encountered by this project were related to programming and management. The phasing of the construction of clinical facilities with staff training was not well coordinated; this re- sulted in understaffing of new facilities. In addition, clinics were often not located near the people they were to serve and construction took con- siderably longer than planned. 3.14 Funds from the loan were used in 1974 for a Health Sector Assessment. It was carried out by a group of Dominicans and several USAID advisers, and resulted in a comprehensive report published in February 1975. This assessment, undertaken almost concurrently with the preparation and appraisal of the pro- posed project, has been an important contribution to the understanding of the current health/family planning situation in the Dominican Republic; its findings, conclusions, and recomnendations provided a useful background for the final formulation of this project. They were also used by USAID to define the health project to be financed by the new loan (signed in October 1975 for US$4.8 mil- lion) aimed at: (a) Low-cost primary health care through the use of lay workers; (b) A nutrition program including nutrition education, which would have as priority target groups young children and pregnant women (this component is attached to the Secretariat of Agriculture); (c) A sample collection of vital statistics designed to improve the statistical information system; and (d) Various technical assistance and training activities designed to assist the Government in the reorganization of SESPAS (along the lines specified in Annex 8, Section A, III) and conducive to an effective health delivery system. 3.15 The proposed Bank-assisted project and the activities of other donors are all parts of the comprehensive Government family planning and health pro- gram. Coordination among donors has been effected through close and frequent consultations. Particularly, complementarity between the USAID project and the proposed Bank project has been discussed in detail between the staffs of the institutions. C. Fami-ly Planning Program Performance 3.16 At the start of its activities, CONAPOFA established explicit de- mographic objectives. However, events have shown that these were far too op- timistic, even after subsequent revision. For example, CONAPOFA's First Five- Year Plan (1969-73) targeted a decline in the birth rate from 47 to 38 per thousand. Early in 1973, the goal was reset as a birth rate of 42 per thousand by the end - 13 - of that year. The study of the health sector by USAID in 1974 estimated the birth rate in 1973 at 45. While the original plan called for 20% of women in fertile ages to be using contraceptives by 1973, after four years of operation this target was pushed forward to 1976. Even this revision seems far beyond reach in view of a recent (June 1975) finding that only about 6.5% of the fertile women were active users of family planning services. 3.17 There are many constraints to family planning in the Dominican Republic which help explain the present low practice of contraception. The country is still predominantly rural, educational levels are low, infant mor- tality is high, and marriages and common-law unions occur at an early age; all of these factors contribute to high fertility rates. The great majority of women live in areas where they do not have ready access to services, and where services are accessible, hours are often inconvenient, waiting periods are long, and the choice of methods somewhat restricted. There is in all likelihood an unmet demand for family planning services in the country. 3.18 During the first two years of the program about 40% of the new ac- ceptors selected IUDs, another 40% the pill, and about 20% other less effec- tive methods. In recent years, pills have been the method chosen by the major- ity of new acceptors. In the last semester of 1975, only 8% of-the new accep- tors chose the IUD. This trend is unfavorable to program performance since the IUD has proved to be the most effective form of contraception among reversible methods. Trained personnel and suitable clinic facilities are needed for IUD insertion and a shortage of these has influenced the choice of devices among new acceptors. 3.19 The strategy that would most likely lead to better program performance would be to increase the supply of maternal and child health (MCH) services and facilities, through which pre-natal and post-partum family planning would be emphasized. This would include enforcing the eight-hour a day regulation for clinic services, making the clinic hours more convenient, expanding the number of service points, and training staff in both human relations and dinical pro- cedures. The extension of service points and the strict enforcement of eight- hour clinic sessions is directly related to the need for additional personnel, particularly nursing personnel and facilities, which the proposed project would help provide. 3.20 In view of the scarcity of doctors in rural areas, CONAPOFA has re- cently, with the assistance of the Population Council and UNFPA, introduced the utilization of paramedical staff for direct family planning services. During 1974, it provided a few nurses with special training to prescribe the pill and insert IUDs. More graduate nurses and nursing auxiliaries need to be trained to extend the family planning services to a greater portion of the population. The proposed Bank loan would assist by helping to finance training, equipment, materials and facilities. - 14 - IV. THE PROJECT A. Obiectives and Strategy 4.01 This three-year project is designed to assist the Government in developing a comprehensive health/family planning program that would, in the long run, significantly reduce the rate of population growth while enhan- cing the health and welfare of the population, particularly of mothers and children living in rural and semi-rural areas. The lack of a viable organiza- tional structure for the delivery of basic health services has been a serious constraint to the establishment of a strong family planning program. In September 1973, the SESPAS proposed a health policy stating the objective of shifting the emphasis from curative to preventive health activities, giving priority to the most vulnerable population groups (defined as children under 15 and mothers) and giving more facilities to the rural population, rather than continuing the concentration on hospital-oriented curative services prin- cipally in the urban areas. This shift would result in an improved health status of the population, which would in turn produce considerable savings in curative services. 4.02 In order to accomplish a reorientation of the existing health pro- grams, the Government has decided to expand SESPAS' existing services and facilities, extending them outward from the urban centers, and to develop simul- taneously niew channels outside of SESPAS for delivering health services to the village level by drawing on such groups as the National Malaria Eradication Service and CONAPOFA. Additional rural clinics would be built by SESPAS and staffed with trained auxiliary health workers who would go from the clinics into the villages both to educate people in preventive health measures and to treat the sick. The USAID loan to the Dominican Republic, signed in October 1975, includes the financing of a low-cost community health program trying to provide preventive health services to the rural village population using prin- cipally semi-autonomous organizations such as the National Malaria Eradication Service. These activities will be absorbed within the regular SESPAS services when those have developed the requisite managerial and administrative capabili- ties. 4.03 The proposed project would support the expansion and improvement of SESPAS' facilities and services focusing on Health Regions I and V, as a first step to a nation-wide improved comprehensive health delivery system (Annex 7 describes the concept of comprehensive health care). 4.04 In order to implement the shift of emphasis from curative to preven- tive services (including family planning) in Regions I and V and to prepare for future extension to the other Health Regions, the proposed project would include components at the national level intended to: (a) increase significantly the number and quality of nursing personnel, (b) assist CONAPOFA to establish im- mediately a strong program of staff training and public motivation in family - 15 - planning in the whole country, and (c) assist local universities in reviewing and making relevant modifications in the curricula of health professions, and in undertaking training in health administration and other continuing education programs for health/family planning staff. 4.05 The Government recognizes the need for reorganizing and considerably strengthening SESPAS at the central level as a requisite for expanding health services and for replicating the experiences of Regions I and V in other Regions of the country, as well as for making effective use of other international assis- tance in community health services and family planning. Changes in SESPAS' structure would include the creation of a planning and programming department under which one unit for human resources and another for planning physical facil- ities would be located. Also,. the staff and functions of the Maternal and Child Health Unit would be expanded. In late 1975, SESPAS appointed a senior official to direct the planning of the reorganization. As a first step, SESPAS, with the assistance of PAHO/WHO and in fulfillment of USAID loan requirements, has defined advisory service needs in administration and has received proposals from several management consultant firms. The selection of the firm which will advise them in the administrative reform will be completed in one month's time. Financing for these activities is provided through the USAID health loan (see Annex 8, Section A, III). During negotiations, assurances were received from the Government that it intends to continue pursuing these activities and to im- plement its reorganization no later than one year after loan effectiveness. B. Project Components 4.06 The project consists of the following specific components: I. Clinical Services and Facilities (a) In Regions I and V, construction, equipment and furniture for eleven rural clinics in Region I and for one health sub-center and 15 rural clinics in Region V; (b) In Regions I and V, radio-communication equipment to connect rural clinics and sub-centers with hospitals and ambulance services, and about 35 vehicles; (c) In Regions I and V, travel allowances for medical and nursing super- visory staff, nominal allowances for auxiliaries working in difficult areas and allowances for medical and nursing students posted in rural clinics; (d) Operating costs for a program of community-based distribution of contraceptives in rural areas and urban slums (partly in Regions I and V), to be implemented by the SSID under the supervision of CONAPOFA; - 16 - (e) At the central level, project preparation and Project Implementa- tion Unit expenses; and (f) Technical Assistance-l/ (i) Twelve man-months of senior and 12 man-months of associate advisory services to the Regional Directors of Health Regions I and V, for administration and for estabLishing a statistical information and program evaluation system; (ii) Twelve man-months of senior and 12 man-months of associate ad- visory services to the local universities, the Regional Health Directors and the medical and nursing supervisors of Regions I and V, for the management and operation of re-oriented compre- hensive community health/family planning services; (iii) Ten man-tmonths of senior advisory services and 36 man-months -of research services to CONAPOFA and local universities, to design and carry out research on the determination of additi a pro- gram efforts, effectiveness of various strategies and determi- nants of reproductive behavior and to analyse the data from the National Fertility Survey; (iv) Twenty-four man-months of advisory services to the Project Director, to design a study for evaluating utilization of buildings, to establish procurement procedures, and to organize a training program in maintenance; and (v) External auditing services. II. Training Activities (a) Nursing and Auxiliary Personnel Creation: (i) 850 six-month fellowships for basic training21f of auxiliaries in the national Nursing Auxiliary Training Centers (CAAEs); (ii) 440 two-year fellowships for basic training of technical nurses in secondary schools (liceos); (iii) 168 three-year fellowships for basic training of graduate nurses in national nursing schools; (iv) Four minibuses (to be assigned to nursing schools and liceos, through SESPAS); (v) Equipment and teaching material for three national nursing schools; and 1/ Terms of reference for consultants are presented in Annex 8, Section A,I. 2/ Basic training refers to officiaLly-approved programs leading to a degree or qualification. - 17 - (vi) Equipment, teaching materials and books for the Nursing Auxiliary Training Centers and for three courses for techni- cal nurses in national liceos. (b) Comprehensive Health Care and Family Planning Training: (i) Audiovisual equipment and teaching material for CONAPOFA's family planning training program in each of the six Health Regions; (ii) Six vehicles for CONAPOFA; (iii) Travel allowances for six new Regional training coordinators of CONAPOFA and their staff; and (iv) Travel allowances and fees for tutors and lecturers for courses and seminars given by SESPAS, CONAPOFA and other agencies.l/ (c) Technical Assistance: (i) Ten man-months of advisory services to national medical schools, to revise curricula to include comprehensive community health care and family planning, and to national nursing schools, to reorient their programs to make them responsive to the country's needs; and (ii) Four 12-month fellowships abroad and six months of study tours, to SESPAS' and CONAPOFA's planning and programming staff. C. Detailed Project Features Experimental Community Health Program in Regions I and V 4.07 In view of the shortage and uneven distribution of health personnel in the country and the constraints imposed by the lack of a viable organizational structure for the delivery of basic health care, the service and physical facil- ities components of the project would concentrate, as an initial stage, in Health Regions I and V,2/ to implement the integration of family planning services with an effective health system (rather than attempting to cover the entire country at one time). These Regions were selected by the Government because they are currently the most deficient in adequate health facilities; / a large propor- tion (an estimated 40%) of the nearly one million people living in these two Regions 1/ A detailed list of courses is presented in Annex 8, Section B. 2/ Health Region I, recently created by subdividing the previous Region IV into two parts, isin the Southwest, bordering with Haiti, and comprises the fol- lowing provinces: Estrelleta, San Juan, Azua and Peravia. Health Region V includes the east side of the country and is formed by the provinces of San Pedro de Macoris, El Seibo, La Romana and La Altagracia. 3/ In Region I, SESPAS operates six hospitals, five sub-centers and eleven rural clinics; IDSS operates three polyclinics. In Region V, SESPAS operates six hospitals, six sub-centers, six rural clinics and two health centers; IDSS operates two hospitals and one polyclinic. - 18 - do not have access to any health service. Furthermore, the extension of ser- vices through the project, particularly in Region I, would complement current national plans for integrated regional development. The Office for National Planning (ONAPLAN) is now working, with UNDP assistance, on the design for a program of integrated rural development in the Southwest, which requires the concerted efforts of several sectors (i.e., agriculture, education, health, etc.); within that framework, the project is welcomed as a needed complement by ONAPLAN and the UNDP.- 4.08 Both Regions are predominantly rural, with high birth rates. Region I, with about half a million population has two towns with around 40,000 inhabi- tants each and one with 30,000 inhabi.tants. The rest of the population live in small towns of less than 10,000. The Region is backward and agriculturally poor. However, most of the typical Dominican crops (except for sugar cane) can be grown under irrigation in this Region, and extensive areas have good potential for considerably improved production with proper irrigation and application of efficient farming techniques. The present plans for integrated development take this potential into account. Region V, in the Southeast, is characterized by a concentration of sugar plantations and the presence of transient Haitian workers who come to cut sugar cane. The socio-economic status of a large part of the population is low. Region V contains one city of about 80,000 people, four large towns of about 30,000-40,000 each, and seven small towns of perhaps 3,500 each. The remaining 200,000 population live in rural locations and do not have access to any health services. 4.09 Under the proposed project, eleven rural health clinics in Region I and 15 rural health clinics and one health sub-center in Region V would be built, equipped and staffed to serve selected rural locations. Each of the two Health Regions would be provided with a two-way radio communication system. The sub-center would consist of an out-patient unit and a maternity ward with 30 beds, staffed with two or three doctors, one graduate nurse, 16 nursing auxiliaries, seven other health professionals (e.g., pharmacist, laboratory technicians, dentist), one statistician, and support and maintenance staff; it would provide outpatient consultation eight hours daily, for sick people, prenatal and child health care, immunizations, family planning advice and ser- vices and nutrition demonstrations. Living accommodations for the doctors and nurses would be part of the compound. The sub-center, to be located in a city of 40,000 (Hato Mayor), would have a daily workload of 100-120 persons; of-this number it is expected that 50% to 60% would be women and children. Family plan- ning talks would be given by a promoter to women visiting the sub-center for any reason. In addition, family planning services would be available during all hours of clinic service. 4.10 The 26 rural clinics would be located in villages of about 2,500 to 3,000 persons living within a 5 Km radius and about 12,000 persons in a 10 Km radius. Each clinic would be staffed by a nursing auxiliary, an assistant who would also be in charge of keeping records, and two full-time resident medical students who would give both curative and preventive care. Housing for the staff - X 9 - would also be provided. These clinics would be open eight hours a day to the public and would provide first aid and treatment for simple cases and the following preventive services: pre-natal and routine pediatric checkups, family planning services and vaccinations. The workload would be about 40 patients daily, of which it is expected that 50% to 60% would be women and children. The project would provide travel allowances to doctors and nurses for supervision visits, nominal allowances to auxiliaries working in rural clinics and living allowances to medical and nursing students posted in rural clinics. The auxiliaries would keep the clinics open eight hours daily and would undertake preventive health care and family planning work in the com- munity. During negotiations, the Governmentagreed to cause the SESPAS, in consultation with the Directors of- Health Regions I and V, to staff adequately the facilities included in-the project with trained and qualified personnel. It also agreed that it will pay wages only to the staff that are performing duties in their assigned posts, and will assume all recurrent costs during the project period , and for at least 15 years thereafter, as required for the ef- ficient operation of its health services. 4.11 Staff from both types of facilities would undertake home visits -- pre- ventive health work -- on a rotational basis. Each staff member could take care of 50 to 75 households, visiting each home an average of 1.5 times per month. They would: (a) maintain a simple record of the members of each family; (b) promote family planning and issue contraceptives (condoms and pills); (c) weigh pre-school children each month; (d) promote child feeding and hydration guided by a weight chart; (e) assemble children and others for immunization at annual intervals; and (f) refer patients to medical facilities as required.l/ IUDs would be inserted by supervisory staff (doctors, nurses) who would visit the rural clinics weekly. Field workers from the ODC, the CEA, the Dominican Agrarian Institute and the Department of Agricultural Extension of the Secretariat of Agriculture would act as health and family planning promoters and would perform a part of the above-listed functions to assist the health staff, by coordinating the home visits with them. The distribution of families and motivational func- tions between the promoters and the health staff would need to be clearly de- fined to avoid duplication and overlap. The monthly work schedules would be prepared by the health team with the assistance of their supervisor. The com- munity-based health system in Regions I and V would be monitored and evaluated through an information system to be established through this project. Techni- cal advisory services would also be provided. (Terms of reference for techni- cal assistance for the management and operation of this community diagnosis program are included in Annex 8.) During negotiations the Goverrment agreed to take the necessary measures to cause the above-mentioned agencies to parti- cipate in the project. 1/ Basic to all these services is educating the people to assume more respon- sibilities for their personal, family and community health. The staff could increasingly involve community leaders, on a volunteer basis, to assume some of the above-mentioned functions. - 20 - 4.12 Several medical schoolsi} have indicated their willingness to par- ticipate in a program with the SESPAS which would consist of fielding their medical students for specific periods to provide health services following the concept of community-based health care. They would also use these ex- periences to review and, if necessary, revise their curricula. During nego- tiations, agreement was reached with the Government that, within six months after loan effectiveness, the Government would enter into agreements with at least three Dominican universities with medical schools to undertake, inter alia: (i) to assign their medical students for field practice in Regions I and V for such- periods of time as shall be necessary to ensure the continuity of the health services in such Regions; (ii) to train SESPAS' field personnel in community-based health services; and (iii) to review and, if necessary, to revise the curricula in their medical schools to reflect the emphasis on preventive and com- munity health services including maternal and child health care. 4.13 UCMM's Nursing School has indicated interest in participating in a similar program with their nursing students. During' negotiations, agreement was reached with the Government that, within six months after loan effective- ness, the Government would enter into an agreement with at least one Dominican university with a nursing school, whereby such university shall undertake inter alia: (i) to assign its nursing students to work in rural clinics for such periods of time as shall be necessary to ensure the continuity of health services in rural areas; and (ii) to review and, if necessary, to revise the curricula in its nursing school to introduce the concept of community-based health care, emphasizing preventive serviees, including maternal and child health care. 4.14 The Government also agreed during negotiations to cause SESPAS' nursing school (ENE) to undertake the actions indicated in para. 4.13 (i) in Regions I and V and to undertake the steps indicated in para. 4.13 (ii). 4.15 About 40 medical and 20 nursing students would be working in Regions I and V at all times. Third-year medical students from t-he Instituto Tecnol6- gico de Santo Domingo (INTEC) and medical and nursing graduates from the other schools would do their field experience working in rural clinics and sub-centers providing comprehensive curative and preventive care (including family planning) 1/ The interested schools at the time of the Bank missions were the INTEC and the UNPHU. -21 - together with the nursing auxiliary as explained in para. 4.11. The facul- ties of the universities would provide supervision to students and contribute to retraining SESPAS field personnel in community health. The project would provide housing for a totdl of 60 students in 26 rural clinics and one sub- center. 4.16 The project activities described above (paras. 4.11-4.1j5 would assist in the provision of comprehensive community health and family planning services to about 200,000 people (or 33,000 families) by end-l977, abou-t500,0O0 pje6ople (or 82,500 families) by end-1978 and about 800,000 people (or 134,000 families) by end-1981. The benefits of the project would reach 90% of the Regions' rural population and parts of urban and suburban areas (see paras. 6.01-6.05 for estimated project effects). Family planning activities would (a) by end- 1977 reach directly 40,000 fertile women of whom 6,000 (15%) would be expected to be contraceptive users; (b) by end-1978 it would reach directly 100,000 fertile women of whom 22,000 (22%) would be expected to use family planning; and (c) by end-1979 it would be reaching 120,000 women of whom 30,000 (25%) would be using the serviees. The crude birth rate in the two Regions would be expected to decrease from 47 in 1973 to 41 in 1980 mainly as a direct result of these services. Training and Research Proiect Activities of National Scope 4.17 Several components of national scope have been included in the pro- posed project to facilitate the future expansion of an effective health and family planning service delivery system throughout the entire country. These components are intended to: (a) Alleviate the shortages of nursing personnel by almost doubling their number by '1980; (b) Reorient the medical and nursing students to enable national uni- versities to graduate'nurses and physicians who will 'be better pre- pared to meet the country's service needs; and (c) Strengthen the current family planning training, motivation and research programs of CONAPOFA so that this agency will be able to make a full contribution to an expanded delivery system in two to three years' time. 4.18 In order to alleviate the shortage of nursing personnel in the country, the proposed project would provide equipment, teaching material, books, vehicles and about 168 fellowships of three-year duration to increase the pro- duction of graduate nurses in the national schoolsl' from an annual output of 40 graduates in 1976, to 70 by 1979 (Annex 5, Table 3 gives details on grad- uate nurse projections). SESPAS is currently unable to fill all vacancies for graduate nurse positions; this increased production would easily be absorbed by - the Government (SESPAS, IDSS) and the private sector. 1/ There are now three nursing schools - one in Santiago, in the Universidad Catolica Madre y Maestra; one under SESPAS, the Escuela Nacional de Enfer- merfa; a third school started in June 1976, at the Universidad Aut6noma de Santo Domingo. The SESPAS school might eventually (1978-79) be absorbed by two universities; this is being planned in an orderly manner, so that it will not affect the production of nurses. Equipment and resources from that school would in time be transferred to the respective universities by the SESPAS. - 22 - 4.19 The project would also assist in producing sufficient numbers of technical nurses, a new category of nursing professional to be trained in liceos in a two-year course, after four years of secondary education (see para. 2.13). To this end, the project would finance equipment, teaching material, and vehicles for initiating courses in three liceos during 1977- 79, and 440 two-year fellowships for candidates from areas where this per- sonnel is needed. 4.20 Nursing auxiliaries are a key to the delivery of low-cost health services and the expansion of the family planning program. The production of this personnel would be stepped up through this project (from 200 completing the six-month course in 1976, to 270 in future years). The project would finance 850 fellowships of six-months' duration for the students in the CAAEs and would provide these centers with equipment, teaching material and vehi- cles. 4.21 As part of this project's preparation, the SESPAS entered into ar- rangements with the UASD, which conducted a semester course (completed in November 1975) in pedagogical methods to prepare 20 tutors needed for all the training activities described above., 4.22 During negotiations, the Governmentagreed to take the necessary measures to ensure that each fellowship recipient described in paras. 4.18-4.20 signs a contract with SESPAS to the effect that, upon completion of the studies, the recipient will work in the services of that agency, in the location agreed at the moment of contract signing, for a period of at least two years; the contract will specify that failure to fulfill this obligation would result in cancellation of the fellowship and obligation to repay the cost of the fellow- ship to the Government.i 4.23 During negotiations, the Goverrnment agreed that during the period of five years starting January 1, 1977, it will create positions within SESPAS for graduate and technical nurses, throughout the country, but mainly in rural areas, such that employment is ensured for the graduates of the fellowship program in- cluded in the project. 4.24 The universities participating in the proposed project should be able to translate the experiences of the health-based community program of Regions I and V into suitable curricula for all their medical and nursing students. The agreements referred to in paras. 4.12 and 4.13 (that would be signed by SESPAS with the universities participating in the project ) should contain provisions to the effect that those universities would review and, it necessary, modify curricula as appropriate. In order to assist in this curriculum modification, the proposed project would finance ten man-mnonths of technical advisory services under terms of reference included in Annex 8. - 23 - 4.25. As noted, the project would include components intended to com- plement the current family planning training, motivational and research pro- grams of CONAPOFA to enable this agency to Tmake a full contribution to an ex- panded delivery system. The proposed project would finance courses on com- munity health care and family planning for about 400 community development and other field workers throughout the country which would be implemented by ODC, the CEA, the Dominican Agrarian Institute and the Department of Agricultural Extension of the Secretariat of Agriculture, with assistance from CONAPOFA. After this training the field workers would be motivators within the communities where they perform their regular development work. They would also incor- porate population and family planning as topics in group discussions, through which they would reach over 130,000 persons, including military personnel and community leaders from all over the country. 4.26 One important function of CONAPOFA as the coordinating agency of the national family planning program is the administration of training and motiva- tion programs. Since its establishment in 1968, CONAPOFA has trained 570 staff. The backlog not trained was over 6,000 in 1976. This function has been ham- pered by over-centralization and lack of staff. This agency should have field staff to plan, organize, monitor and, if necessary, conduct family planning training programs for the different agencies. In response to this need, the proposed project would finance travel allowances for six family planning train- ing coordinators and their staff; a team would be assigned to each of the six Health Regions in the country. The functions of the coordinators and their staffs would include: (a) assessing family planning training needs for all agencies in the respective Region; (b) defining the roles of the various categories of personnel in family planning and the skills they would need to acquire and set priorities; (c) helping to prepare and organize and, if necessary, conduct training programs under guidelines provided by CONAPOFA; and (d) evaluating training programs. 4.27 The proposed project would also include financial assistance to CONAPOFA for conducting one national and nine regional seminars to facilitate discussions on population and family planning among teachers of normal schools (teachers of teachers) throughout the country. These seminars would be conducted during the three years of the project for about 300 teachers in anticipation of the eventual introduction of family life and population education in schools. The decision for the timing of these latter activities rests with the Government through its Secretariat of Education. 4.28 , As explained in para. 4.02 the Government has decided to expand SESPAS existing services, extendingithem outward from the urban centers and shifting the emphasis from curative to preventive health activities, giving -24- priority to the most vulnerable groups (defined as children under 15 years and mothers). It has also decided to develop new channels -- through the USAID loan -- using lay health promotors. However, the implementation of this policy nation-wide will take at least five years. In the meantime, in order to make family planning services available immediately in selected rural and urban slum areas not covered by hea'lth services, this project would finance the program of a private organization -- the SSID -- for community-based dis- tribution of contraceptives (CBD) using voluntary lay distributors (details of this.component are presented in Annex 9). As health services become available in the areas served by the CBD program, the latter would transfer its regular family planning u4sers to the Governmient program and it would, move its activi- ties to other localities lacking basic health aervices. In January 1977, the CBD program would begin in 200 local.ities of over 2,000 population, loca- ted in eight provinces (four of which form part of the project areIas). -the ad- ministration of the CBD program consists of a Program Director; 1 medical ad- visor, 1 assistant to the Director, I secretary and 8 provincial coordinators (11 salaried staff); and 200 voluntary distributors who receive, as incentive, 15 cents per contraceptive unit sold at 25 cents each (1 pill cycle, 1 foam can, 12 condoms). Contraceptives are donated to the program by the Church World Service. The CBD program is now serving about 9,000 regular users. The goal for the program, as part of this project, would be to recruit 125 nlew acceptors per province, monthly, and to serve the regular users. The objectives of this component are: (a) To distribute non-clinical contraceptives without professional supervision; (b) To distribute pills prescribed by doctors or paramedical personnel and to refer cases to CONAPOFA/SESPAS' clinics; (c) To distribute all types of contraceptives to private family planning services located in child care and nutrition clinics spo'nsored by the SSID; (d) To distribute all types of contraceptives to the famil y planning services operating in medical outpatient clinics sponsored by the SSID; and (e) To promote family planning voluntary services among private doctors, nurses and auxiliaries. 4.29 During negotiations the Government agreed to enter into an agreement with the Social Service of Dominican Churches (SSID) to the effect that th.at agency will undertake a program of community-based distribution of-contracep- tives and promotion of family planning methods in pre-selected areas of the country not covered by basic health services. - 25 - 4.30 As noted, the proposed project includes construction of and equip- ment and vehicles for 27 health service facilities in Regions I and V. At the present time there is no system of maintenance of health facilities and equipment in the country. In order to ensure proper maintenance of build- ings and equipment, both in the case of the new project and existing health facilities, and in anticipation of future expansions of the system, the pro- posed project would provide technical assistance for organization of in-ser- vice training in maintenance for six engineers (one in each Health Region) and other related health staff, under terms of reference presented in Annex 8. Maintenance functions within SESPAS would be institutionalized and would be- come a permanent activity under the responsibility of a future "Physical Facilities Planning and Maintenance Division" (para. 5.10 and Annex 10). Research and Evaluation 4.31 CONAPOFA recently created Evaluation and Research Divisions (para. 3.06 and Annex 6). A new statistical system has been established to collect, process and analyze family planning information from clinics. The new system represents a considerable improvement over the original system. The Research Division is responsible for undertaking studies to help establish program priorities and research on the effectiveness of various communication stra- tegies and on attitudes toward birth control methods. However, there is con- siderable latitude for expanding this Division's functions to make full use of research capabilities available in national universities. The project would include technical advisory services for assisting CONAPOFA and local universi- ties to prepare a research program for the former and to design research focused on studying, inter alia: (a) sociological factors bearing on-the health/ family planning delivery system; (b) the impact of various economic conditions on that system; (c) the effectiveness of the health team under various stra- tegies for delivering health/family planning services; and (d) the degree of utilization of health facilities (both existing and new) with a-view to more efficient criteria for location and design for future facilities. The project would finance implementation of research projects in these areas, as well as an analysis of the data from the National Fertility Survey. 4.32 For evaluation of the family planning program and the project, re- spectively, the proposed project would rely on the present statistical system of CONAPOFA and the new health statistical system to be initiated in Regions I and V. During negotiations, the
Группа Всемирного банка · Staff Appraisal Report
Dominican Republic - Population and Family Health Project
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